PERIOPERATIVE NURSING (2015), VOLUME 4, ISSUE 3

REVIEW ARTICLE

BIRTH RELATED TRAUMATIC BRAIN INJURY - NURSING INTERVENTIONS Michail Kokolakis 1, Ioannis Koutelekos 2 1. BScN, Neurosciences, King’s College Hospital, NHS Foundation Trust U.K. 2. Lecturer, Faculty of Nursing Technological Educational Institute (TEI) of Athens, Greece DOI: 10.5281/zenodo.35310 Abstract Traumatic brain injury is a major cause of serious harm and death in newborn infants. The injury affects not only the infant but also impacts heavily on close relatives. They also will need professional assistance. Caring for infant patients with traumatic brain injury is perhaps the most difficult of many professional challenges for nursing staff, requiring both technical and skills and sensitivity to the needs of the relatives. The purpose of this article is to highlight the most important nursing interventions. Objective: The aim of this study was to review recent publications specifically addressing nursing intervention in the care of neonates with traumatic brain injury. Sources and materials: The approach to this article centers on research and review of studies between 2007–2015, from the online sources of Pubmed/Medline, Elsevier, Saunders Medical Center, Lippincott Williams and Wilkins, New England Journal of Medicine, The Journal of Head Trauma Rehabilitation and the Journal of Neuroscience. The literature featured in this article refers to nursing intervention in cases of neonates with traumatic brain injury, identified through key words such as: nursing intervention in neurosurgery, nursing intervention in neonates with cranial trauma, head injuries and nursing care, nursing neurological assessment. Results: The most recent studies emphasize that nursing interventions in the case of neonates who have sustained traumatic brain injury should be provided by specially trained persons who have acquired the skills and knowledge within this particular speciality area. Essential to successful outcomes of nursing interventions are frequent training and tutoring sessions where the nurse, in conjunction with the doctor, will be able to find, understand and apply scientifically competent solutions to meet the exact needs of the case. The role of the nurse should follow a personalized plan clearly defined as part of the total care and welfare of the neonate. Conclusions : Successful nursing interventions for the care of neonates with traumatic brain injury include improvement of the neurological status and achieving a better outcome. However, there are few researched facts in the literature that document the detail of the nursing interventions performed. This suggests that further studies of the nature of the nursing interventions are necessary. Key-words: Nursing intervention- neonates- traumatic brain injury Corresponding author : Dodekanisou 11, Glyphada, 165-62. Tel : 6940693037 [email protected].

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Introduction Birth related traumatic brain injury occurs with the interventions of external forces and can result into tissue and cellular damage of the brain. Such an incident can lead to permanent or temporary impairment of cognitive, physical, psychosocial functions, and a diminished or altered state of consciousness. (1) Despite efforts to prevent birth related brain trauma, it remains the most common cause of injury and death in neonates. (2,3) Traumatic brain injury most often occurs during labor and leads to a number of conditions such as caput succedaneum, cephalohematoma, subgaleal hemorrhage, subdural hemorrhage, subarachnoid hemorrhage, epidural hemorrhage, cerebellar hemorrhage, intraventricular hemorrhage and skull fractures. Infants with greater risk for birth related injuries include those above the 90th percentile for weight (>3500g), infants that are in an abnormal position during labor and delivery, when the mother’s pelvis size or shape is not adequate for vaginal birth, difficult labor or delivery, Braxton Hicks contractions, prolonged labor, fetal anomalies, very low birth weight and extremely premature infants. (2) Extracranial Hemorrhage Extracranial hemorrhages are one of the most common complications of instrumentassisted deliveries and are characterized by a bleed that is situated outside the cranium. Risk factors other than instrument-assisted deliveries include primigravidity, hypoxia, cephalopelvic disproportion, difficult and prolonged labor and coagulation disorders. There are three major types of hemorrhages: caput succedaneum, cephalohematoma and subgaleal hemorrhage. These lesions occur in

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different parts of the tissue between the skin and the cranial bone. (2) Caput succedaneum A caput succedaneum is an edema of the scalp caused by a bleed below the scalp and above the periosteum and involves a serosanguinous, subcutaneous, extraperiosteal fluid collection with poorly defined margins caused by the pressure of the presenting part of the scalp against the dilating cervix during labor. (4,5,6) It does not indicate damage of the brain or the bones of the cranium. Although caput succedaneum can occur in the absence of risk factors, incidence increases in difficult or prolonged labor, with premature rupture of the amniotic membranes, in primagravidas and in instrument-assisted deliveries. The risk of such complication during labor is estimated at around 5% and are more common with vacuum extraction delivery than with forceps with a ratio of 14-16% vs 2% respectively. (7) Caput succedaneum is manifested immediately following delivery and gradually decreases in size thereafter. The scalp edema may cross over the sutures lines and the caput is generally 1-2 cm in depth and varies in circumference. (6) The most common presentation of caput succedaneum is symptomatic with findings such as soft or puffy swelling on the scalp, bruising or color change on the scalp and swelling that extends across the midline and over the sutures lines. The edema usually heals in hours to days and rarely has any complications. (8) In order to diagnose a caput succedaneum there is no need to perform a formal test. Diagnosis is usually made with a physical examination and inspection of the scalp. The condition almost always resolves itself in a couple of days, and there is rarely any long-term complications.

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However in rare cases if left untreated, the swelling caused by a caput succedaneum can break down into bilirubin and the neonate may develop jaundice which can posses a threat if not treated (kernicterus). (9,10) Nursing care most often involves parent education which includes the cause of the tissue swelling and complications that might present. (2) It is very important to measure the head circumference every 24 hours and to record and report any possible defects of the scalp. As the edema withdrawals it is necessary to perform a physical exam of the scalp in order to diagnose any abnormalities. (2,11)

by 2-3 days of age. (2) In rare occasions complications such as anemia, infection, unnatural bulges and jaundice can be noticed, although it is unlikely for a hematoma to contain enough blood to affect hemoglobin and bilirubin levels. The condition can also be accompanied with intracranial lesions that can lead to death. (13) Apart of a physical exam which can lead to a diagnosis, a computed tomography scan is an important means of detecting the hematoma. A computed tomography can also detect linear skull fractures which can be accompanied with cephalohematomas at around 10-25% of times. One must not forget that cephalohematomas are internal and

Cephalohematoma A cephalohematoma is a traumatic subperiosteal hemorrhage of blood that occurs between the periosteum and the skull of a newborn baby secondary to the rupture of a blood vessel crossing the periosteum. It is typically over the parietal bone and can be seen unilateral (most often) or bilaterally. (2) Birth related cephalohematoma is a medical condition that occurs in 1-2% of all live births. A prospectively study that was performed on live babes, indicates that the condition is more common than any other head trauma and is estimated around 57,2% out of a population of 7154 live babes. (4) Cephalohematoma is seen most often in male infants than female. (2) Also, the condition is more likely to occur in instrument-assisted deliveries (forceps) and after prolonged and difficult deliveries. (2,4) Additionally, vitamin C deficiency has been reported to be associated with this condition. (12) Cephalohematomas are mostly internal with characteristic findings of a firm and tense mass that does not cross the suture line. The mass may become more extensive BIRTH RELATED TRAUMATIC BRAIN INJURY - NURSING INTERVENTIONS.2015;4(3)

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sometimes can not be detected with just a physical exam. (14,15) The condition resolves in time period of a week to two months, occasionally with residual calcification. The calcifications gradually withdrawal as the bones grow and reform. Generally, there are no long-term sequelae from a cephalohematoma. (2) Nursing interventions include monitoring the newborn. The vital signs of the infant should be recorded frequently and the head circumference should be measured every 1224 hours if necessary. Nurses must detect early signs of complications including high bilirubin levels, loss of appetite, fever, anaemia and hypotension. A physical exam of the head should be performed twice a day. Abnormalities and changes of the size and place of the mass must be recorded and reported to the attending physician. Parent education is also part of the nursing role. Parents must be informed about the cause, the complications and the treatment options. (2,16) Subgaleal hemorrhage A subgaleal hemorrhage is the most serious extracranial hemorrhage and results in the accumulation of blood between the skull periosteum and the galea aponeurotica, due to the rupture of large emmisary veins. (17) The hemorrhage may be from suture separation, linear skull fracture or fragmentation of the superior margin of the parietal bone with the bleed spreading beneath the entire scalp and down the subcutaneous tissue in the neck. Blood loss can be significant up to 260 ml which can exceed the total volume of blood in a newborn. (2) Birth related subgaleal hemorrhage has an incidence of 0,2-3 per 1000 live births. (17) It is a condition that is more likely to occur in instrument-assisted

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deliveries and more specific when vacuum extraction is used (90%), but can happen spontaneously. (18) The condition is rare but really serious advert event that when left undetected can result in to poor neonatal outcome or even death. (17) The hemorrhage usually presents as a firm fluctuant mass developing over the scalp (occiput) with superficial skin bruising and spreads across the suture lines. The swelling may increase in size after birth (12-72 hours after delivery). (2) Rupture of large emissary veins connecting the dural sinuses and scalp veins into a large potential space can result into hemorrhage of 20-40% of total circulating blood volume, resulting in hypovolemic shock and may contribute to hyperbilirubinemia. (17) Infection of the blood clot is a complication that can potentially occur in a subgaleal hemorrhage and can lead to a numerous of disorders if left untreated. Diagnosis is made by history taking and physical examination of the head, including measuring the circumference of the head and assessment of the location and characteristics of any swelling. The presence of fluctuance early on, whether or not the swelling is progressive, is an important distinguishing feature of subgaleal hemorrhage. Because the hemorrhage spreads through a large tissue plane, blood loss may be massive before hypovolemia becomes evident. When a subgaleal hemorrhage is suspected, hemoglobin measurement should be performed as soon as possible and should be monitored every 4– 8 hours, as should coagulation studies. Clinical diagnosis with the use of a computed tomography scan can identify the hemorrhage and any underlying skull fractures. (19) Early detection of this clinical emergency is vital. Due to the loss of blood, transfusions are necessary in order to avert hypovolemia. If the bleed has progressed to

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hypovolemic shock, ventilation is required as an aggressive treatment of the resulting metabolic acidosis. Support with inotropic medication may be needed to increase blood pressure and improve cardiac output. Seizure activity is usually treated by using phenobarbital. (20) Phototherapy can be used to treat jaundice through the isomerization of the bilirubin and consequently transformation into compounds that the newborn can excrete via urine and stools. (21) As the subgaleal hemorrhage possesses a real threat to the newborn, nurses have to be alerted in order to detect any symptoms that could lead to evidence of such condition. Symptoms such as anaemia, loss of appetite, prolonged crying, bruising that crosses over the suture lines, poor vital signs and loss of consciousness are indicative of a hemorrhage between the skull periosteum and the galea aponeurotica. Nursing intervention in newborns with increased potential of a subgaleal hemorrhage include measuring the head circumference every 4-8 hours, inspection of the edema and the ears on a hourly basis, monitoring the vital signs (especially the heart rate and the blood pressure) and measuring the arterial blood gasses (hematocrit or hemoglobin, levels of oxygen and the blood acidity). (2,16) The use of the Glasgow Coma Scale every hour is crucial in order to detect any loss of consciousness. Anemia in collaboration with loss of consciousness can be indicative of a hypovolemic shock which has to be treated aggressively. An intravenous line should be inserted in order to administer fluids (saline or blood components) and drugs (inotropic and other) as prescribed from the attending physician. Oxygen administration can be prognostic in order to counteract the blood acidity. (16) Newborns with increased risk of a subgaleal hemorrhage must always be

transferred to the neonatal intensive care unit for additional observation. Last but not least, nurses must engage with the parents preparing them for the likelihood of any complications that it may present due to the underlying condition. Newborns with moderate to severe lesions may require aggressive therapy and up to 25% can die mainly due to hypovolemic shock. Lesser lesions in newborns will dissolve in 2-3 weeks. (2) Neonatal skull fractures A skull fracture is any break or indention in the cranial bone known also as the skull. They are quite a rare occurrence that constitute 2,9% of all neonatal head injuries. Studies have shown that fractures occur more less in vaginal deliveries but the risk increases with instrument-assisted deliveries. Other risk factors that contribute to skull fractures include primiparity, macrosomia, male sex and difficult or prolonged labor. Depressed and linear fractures have been detected sporadically in the newborns, with depressed fractures occurring more frequently than linear. (22) The infants skull can be very flexible but due to its poor ossification it can hardly tolerate any mechanical stressors in comparison to an adult that has a mature skull. Some studies suggest that an impact force equivalent to 280 N can result in a 50% probability of fracture in any part of the cranial bone. In conclusion, due to the immaturity of the infants skull there are indications of lower thresholds for fractures in comparison with an adults skull that need nearly five to eight times the force (14002240 N or more) in order to sustain a fracture. (23) Depressed skull fractures Depressed skull fractures are fractures or indentions of the skull that result in bone

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fragments depressed into the underlying brain tissue. (24) A depressed skull fracture is most often seen (approximately 75% of the time) in the front or parietal region, as the bone is thiner and it is more prone to injury, but does not cross the suture lines. (25) These kind of fractures are almost entirely seen after instrument-assisted deliveries, prolonged or difficult labor and by compressing the fetal skull against the maternal ischial spine, sacral promontory or the symphysis of the pubis but also can be seen in very rare conditions as a spontaneous fracture in uncomplicated deliveries. (2,22) A depressed skull fracture has an incidence approximately 1 out of 1.000 deliveries. (26) The characteristic ping pong skull fracture occurs when the bones are soft and resilient, causing a depression deformity of the bone (like a dent in a ping pong ball). The condition may be symptom free, but signs such as skull deformity, neurological deterioration, bruising, seizures, loss of consciousness, loss of appetite and prolonged crying can be detected as a result of an underlying cerebral contusion or hematoma. Other complications that might be noticed are infections, especially if there is a cerebral fluid leakage or when cysts form which are also called leptomeningeal or growing skull fractures. Diagnosis can be made when overviewing and palpating the skull during a physical examination. The dents which are frequently seen over the right parietal bone of the fractured skull can easily be identified. A computed tomography can also confirm the diagnosis and rule out any underlying brain injury. Treatment options vary depending on the place (frontal, parietal) of the injury and the method used to elevate the skull (manual elevation or surgical operation) if the skull has not recovered spontaneously on its own in the first week. (2,27) Recent studies indicate that early surgery does not

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improve prognosis of victims, although nearly 72% showed good recovery but some senses such as smell and taste are compromised in 50% of patients which will affect their quality of life. (28) Other methods of elevating the depressed skull is the usage of breast pumps, vacuum extractors, gentle pressure and elevation via a percutaneous micro-screw. (29) In the presence of cerebral fluid leakage or hemorrhage, antibiotics and fluids must be administered in order to prevent infections and shock. Studies in rat models with ex-vivo evidence have shown that Ceftriaxone, which is a beta-lactam antibiotic improves cognitive function and relieves brain edema mainly due to the scale down of the excitotoxicity and inflammation after brain injury. (30) Nursing intervention is required from early on. Nurses should be able to successfully provide a physical exam and determine the fracture and also eliminate any underlying conditions such as a hemorrhage. A physical examination must be performed at least once every four hours if the condition is declared as high alert. The neonates vital signs must be monitored and recorded at least every four hours. An assessment with the inclusion of the measurement of the head circumference and the Glasgow Coma Scale must be conducted in order to exclude any neurological deterioration. If possible, monitoring the intracranial pressure or any signs that could suggest high intracranial pressure (hypersomnolence, loss of appetite, vomiting) should be performed. Pupil inspection can also provide evidence of elevated pressure. Seizure activity could be prognostic and it is important to record the attacks and report them to the attending physician. Last but not least a nurse should inform the parents about the potential damage to the brain, the cause and the complications that might occur during

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recovery. Part of the nursing care is to educate parents in detecting signs of increased intracranial pressure or growing skull fractures (leptomeningeal cysts). (2,16,31) Linear skull fractures A linear skull fracture is a break in the bone of the skull that simulates a thin line with the absence of any depression, splintering and distortion of the bone. (32) These kind of fractures are generally seen in the parietal and frontal region as the bone is thiner, but can be seen in the occipital region also. Linear fractures can too be accompanied by cephalohematomas at around 10-25% of times, subdural hemorrhage and in rare cases with intracranial complications. The main cause of this fracture is instrument-assisted deliveries, prolonged or difficult labor, when the fetal is in utero and in rare occasions in uncomplicated vaginal and cesarean birth. (2,33) The incidence of linear fractures are uncharted due to the fact that identification of the lesion depends on the radiographic studies and the physical examination, which means that some fractures remain undiagnosed. (15) The condition is more difficult to detect as there is no deformation of the skull and the newborn may not have any symptoms. It is usually diagnosed while undergoing a routine radiographic study. Although it is a symptom free condition, it can manifest some times in ways such as bruising and edema of the scalp, pathologic changes of the head circumference, seizures, irritability, loss of appetite or more severe loss of consciousness and hydrocephalous (if craniocerebral erosion occurs). Complications are rare and include extracranial or intracranial hemorrhage and leptomeningeal cysts (growing fractures).

These cysts are quite a rarity in an occurrence of lower than 1% of linear fractures, and happen due to the arachnoid membrane trapped between the edges of the fracture, which results in the erosion of the skull caused by throbbing of the arteries. (2) Health providers more often categorize complications of a linear fracture as acute (hemorrhage) or chronic (leptomeningeal cysts and hydrocephalous). As mentioned earlier on, diagnosis is made through radiographic studies, usually with a plain xray and not with a physical examination as there might not be any evidence of a fracture. A computed tomography can be necessary to exclude any complications. Neonates with uncomplicated linear fractures generally do not require any treatment or special management as the fracture heals spontaneously on its own in a time period of four weeks to six months depending on the injury and region. Neurosurgical intervention is necessary if complications develop. (33) Nursing care involves monitoring the vital signs and recording them every four hours, measuring the head circumference at least once daily, a physical examination of the head to rule out any bruising or edema, and the evaluation of the Glasgow Coma Scale in order to determine the level of consciousness. Assessment of the intracranial pressure is not necessary if there is no evidence of complications. Furthermore, a nurse has to engage with the parents and inform them about the cause and the doubtfulness of any complications that might develop. Lastly, parents must be educated in measuring their babes head circumference at least once a week at home and also performing a physical exam of the head at least twice a week to exclude a growing fracture. While visiting their practitioner or pediatrician there are

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instructed to inform them about the linear fracture in order for a more experience evaluation. (2,33) Intracranial hemorrhage A intracranial hemorrhage can occur due to the immaturity of the structure or the hemodynamic instability, and also secondary to trauma or hypoxia. There are five major types of hemorrhages according to the site of origin: epidural, subarachnoid, subdural, intraventricular and cerebellar. Neonatal intracranial hemorrhage is a considerable source of mortality and morbidity. There are many causes and risk factors that could reinforce the condition such as maternal disease (hypertension etc), history of infertility drugs, preeclampsia, ventilator therapy, pneumothorax, difficult and prolonged labor, premature infants, low weight infants (